Provider Demographics
NPI:1811076003
Name:BROWN, TARA D (LAT)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:D
Last Name:BROWN
Suffix:
Gender:F
Credentials:LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1567 ROME HWY
Mailing Address - Street 2:
Mailing Address - City:CEDARTOWN
Mailing Address - State:GA
Mailing Address - Zip Code:30125-4402
Mailing Address - Country:US
Mailing Address - Phone:770-749-7120
Mailing Address - Fax:706-622-4348
Practice Address - Street 1:1567 ROME HWY
Practice Address - Street 2:
Practice Address - City:CEDARTOWN
Practice Address - State:GA
Practice Address - Zip Code:30125-4402
Practice Address - Country:US
Practice Address - Phone:770-749-7120
Practice Address - Fax:706-622-4348
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2017-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0008442255A2300X, 2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1811076003OtherNPI